CITY OF EXCELSIOR SPRINGS, MISSOURI

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Rosa McCormick
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1 CITY OF EXCELSIOR SPRINGS, MISSOURI LIQUOR APPLICATION NOTE: If a corporation makes application, then the answers are to be made by the managing officer of the establishment. As Sole Owner Partnership Corporation Trade Name: Address: Phone No.: 1. Is business to be any type of partnership? If so, list name, address, date of birth and social security number of partner or partners: Name Address SSN DOB 2. Your name: Address: How long have you resided at this address? Phone No.: ( ) A. Are you a registered voter at this address? B. Are you an assessed tax-paying citizen at the above address? 3. Your place of birth Date of Birth Are you a citizen of the United States of America? If naturalized, give date and place of naturalization 4. Sex Age Height Weight Hair Eyes Social Security Number 5. Have you ever been convicted of any crime in any Missouri court, any court of another state, or in any Federal court? If so, give details: 1

2 6. Spouse s name, address, social security number, and date of birth: _ 7. Have you ever been convicted of a felony? 8. Give names and business addresses of your employers for the last five years. If you were self-employed, state nature of business and location: 9. Have you ever been the holder of a permit to manufacture or sell alcoholic beverages? A. If so, where? (Name) (Address) B. Was such permit ever revoked? If yes, give details as to revoking authority, date, offense charged, and disposition: 10. Are you, or any member of your household or immediate family, interested directly in any other license issued by the Director of Liquor Control, State of Missouri, which is now in force? If so, give details: 2

3 11. Have you, or any member of your household or immediate family, ever made application for a license from the Director of Liquor Control, State of Missouri, which was denied? If so, give the name of the applicant, approximate date of denial, and details regarding same: 12. Have you ever been bankrupt or insolvent? _ 13. Is the proposed location within one hundred (100) feet of a church or school? 14. What type of business is the permit to be used for? 15. Give dimensions of room(s) in which alcoholic beverages will be dispensed: 16. From whom was the business purchased? 17. Effective date of possession: 18. Name of mortgage holder: 19. Do you rent or lease the premises for which this business is to be used? If so, give terms of rent or lease and name of the owner of the property: 20. What interest, if any, does your landlord have, directly or indirectly, in the business, which you intend to engage in if the license is granted? 21. Does your landlord now hold or has he ever held a license of any kind issued by the Director of Liquor Control, State of Missouri? Does the former owner of the business have any interest, either directly or indirectly, in the business for which you seek a license? If so, state details: 3

4 22. State names of any person, firm, or corporation that has advanced, or will advance any money to you to purchase or operate the business for which you seek a permit: (If person, give name, address, date of birth, and social security number.) 23. If a RETAILER, does a distiller, wholesaler, or winemaker, brewer, or supplier of coin-operated commercial, manual, or mechanical amusement device, or any employee, officer, or agents thereof have any financial interest in the business or will you either directly or indirectly borrow or accept from any such person or persons equipment, money, credit, or property of any kind except ordinary commercial credit for liquor sold? 24. If a WHOLESALER, does any retailer or supplier of equipment or coin-operated commercial, manual, or mechanical amusement device, or any employee, officer or agents thereof have any financial interest in the business or will you either directly or indirectly borrow or accept from any such person or persons equipment, money, credit or property of any kind except ordinary commercial credit for liquor sold? 25. Will you be the person in active control and management of this business full time? Part time? Other? If you do not operate the business full time, give complete information on proposed or planned management. 26. Is there now employed or do you expect to employ in the business sought to be licensed hereunder, any person who has been convicted of any crimes? If so, state details and give name, address, date of birth and social security number of persons convicted of crime: 4

5 27. Will you at all times permit the entry of any officer or investigator who may have legal supervisory authority for the purpose of inspection or search; and will you permit the removal of all things and articles which may be in violation of the ordinances of Excelsior Springs, Missouri, and the laws of the State of Missouri; and do you consent to the introduction in evidence of such articles in any proceedings for the violation of any provision of the revised liquor control ordinances of Excelsior Springs, Missouri, and/or for the suspension or revocation of the permit which this application is made; and do you promise and agree not to violate any of the ordinances of Excelsior Springs, Missouri, the laws of the State of Missouri, or the United States, in the conduct of the business for which permit is sought? IF BUSINESS IS OWNED BY A CORPORATION, COMPLETE THIS SECTION: 28. Name of Corporation: 29. State in which incorporated: Date of Incorporation: 30. President s Name: Address: Date of Birth: Social Security Number: Vice President s Name: Address: Date of Birth: Social Security Number: Secretary s Name: Address: Date of Birth: Social Security Number: Treasurer s Name: Address: _ 31. List the five largest stockholders and percentages of stock held: Name: Address: Name: Address: 5

6 Name: Address: Name: Address: Name: Address: 32. Is the corporation of any stockholder or the managing officer thereof, or any member of his/her household or immediate family, interested directly or indirectly in any other license issued by the Director of Liquor Control, State of Missouri? If so, please state details: 33. State the name, residence, date of birth, and social security number of each person, or firm, or corporation, and its stockholders, interested, or to become interested, directly or indirectly, other than hereinabove set out, in the business for which a license is sought and the nature of such interest: _ 34. Liquor by the drink applicants must present a petition to the Director of Liquor Control containing the signatures of 51% of the resident property owners owning property within 185 feet of the boundaries of the property where the applicant intends to sell such alcoholic beverages and 51% of the tenants, if any, of said property, indicating that they are not opposed to such activity. This petition must be filed with the Director of Liquor Control before an application can be acted on. 6

7 State of Missouri) ss) County of Clay) I, or we, (please print) being of lawful age and duly sworn upon my/our oath do swear that all answers and statements herein contained are true and complete, and I/we understand that any misstatement or omission of fact on this application will be sufficient cause for disqualification. I/we hereby authorize the verification of the above information on this application. _ Subscribed and sworn to before me this day of 20. My commission expires: Notary Public 7

LIQUOR LICENSE APPLICATION

LIQUOR LICENSE APPLICATION (Any reference to applicant in this document refers to the owner/managing officer.) To be completed by applicant as (check one): Sole Owner & Operator Corporation Partnership